|(a) OIG conducts utilization reviews of nursing facility
providers for residents enrolled in fee-for-service and managed care.
(b) For purposes of this subchapter, Resource Utilization
Group (RUG) means the 34-group case mix classification system selected
by the state and established by CMS or a successor case mix classification
system selected by the state.
(c) A nursing facility provider must conduct accurate,
standardized, and reproducible assessments of each resident's functional
capacity, using a minimum data set (MDS) assessment and the guidance
of the Resident Assessment Instrument (RAI) User's Manual. These assessments
must be conducted on the schedule required by HHSC. All MDS items
coded on an MDS assessment must be in accordance with all applicable
state and federal law, rules, and policy, including:
(1) the RAI User's Manual;
(2) CMS updates to the RAI User's Manual;
(3) 42 C.F.R. §483.20 (relating to Resident Assessment);
(4) administrative rules applicable to Medicaid providers,
including 26 TAC Chapter 554 (relating to Nursing Facility Requirements
for Licensure and Medicaid Certification); and
(5) HHSC and CMS policy guidance.
(d) A nursing facility provider must code on the MDS
assessment only those events occurring during the look-back period.
The look-back period is the assessment timeframe preceding the assessment
reference date (ARD) that is used when coding each item on the MDS
assessment. The ARD is the last day of the look-back period.
(e) Any information on the MDS assessment is part of
each corresponding claim for Medicaid reimbursement.
(f) Electronic or digital signatures on an MDS assessment
must comply with the RAI Manual and Texas Business and Commerce Code
(g) A complete MDS assessment must include:
(1) a valid, supporting Long-Term Care Medicaid Information
(LTCMI) form, or successor form required by HHSC, which the nursing
facility provider must maintain with the corresponding MDS; and
(2) the signature and title of each person completing
any section of the MDS assessment for Medicaid reimbursement and the
sections and completion dates corresponding to each signature.
(h) Each individual signing the signature section of
the MDS assessment is certifying that the information entered on the
MDS assessment is accurate. Any individual or nursing facility provider
that submits false or inaccurate information is subject to sanctions
under Subchapter G of this chapter (relating to Administrative Actions
(i) Upon request, a complete MDS assessment must be
provided to the OIG nurse reviewer during the onsite or desk utilization
(j) When correcting errors in an MDS assessment prior
to the start of an OIG utilization review, the nursing facility staff
must use the MDS Correction Policy in the MDS RAI User's Manual. The
nursing facility provider must maintain documentation in the clinical
record that supports the corrected MDS assessment. Nursing facility
staff must not correct or modify any MDS assessment reviewed during
an OIG utilization review until after any reconsideration review and
appeal has been finally determined.